Nclex review questions

Nclex review questions.

1. The nurse is caring for a client receiving blood transfusion therapy. Which clinical manifestations would alert the nurse to a hemolytic transfusion reaction? Select all that apply. 1. Headache 2. Tachycardia 3. Hypertension 4. Apprehension 5. Distended neck veins 6. A sense of impending doom.

Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Clinical Judgment/Cognitive Skills: Analyze Cues Integrated Process: Nursing Process/Analysis Content Area: Complex Care: Blood Administration Health Codes: Adult Health: Immune: Hypersensitivity Reactions And Allergy Priority Concepts: Clinical Judgment; Immunity.

Answer:1,2,4,6 Rationale: hemolytic transfusion reactions are caused by blood type or rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life-threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload..

Test-Taking Strategy: Focus on the subject, a hemolytic transfusion reaction. Recall the pathophysiology of this type of reaction to select the correct options. Also think about other types of transfusion reactions that can occur, and recall that distended neck veins are characteristic of circulatory overload. Priority Nursing Tip: The nurse should suspect a transfusion reaction if the client develops any symptom or complains of anything unusual while receiving the blood transfusion. Reference: Ignatavicius, Workman, Rebar (2018), p. 835..

2. A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure would the nurse implement to promote client safety? 1. Use the right arm for blood pressure measurement. 2. Use the fistula for all venipunctures and intravenous infusions. 3. Ensure that small clamps are attached to the AV fistula dressing. 4. Assess the fistula for the presence of a bruit and thrill every 4 hours..

Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Clinical Judgment/Cognitive Skills: Generate solutions Integrated Process: Nursing Process/Planning Content Area: Adult Health: Renal and Urinary Health Codes: Adult Health: Renal and Urinary: Acute Kidney Injury and Chronic Kidney Disease Priority Concepts: Perfusion; Safety.

Answer:4 Rationale: AV fistulas are created by anastomosis of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. Fistulas should be evaluated for the presence of thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency. Blood pressures or venipunctures are not done on the extremity with the fistula because of the risk of clotting, infection, or damage to the fistula. The fistula is not used for venipunctures or intravenous infusions for the same reason. Clamps may be needed for an external device such as an AV shunt, but the AV fistula is internal..

Test-Taking Strategy: Focus on the subject, an AV fistula and safety. Eliminate option 3 first because this refers to care of an AV shunt, in which there is an external cannula that can become disconnected. If accidental disconnection occurs, the small clamps can be used to occlude the ends of the cannula. Blood pressure measurement, insertion of intravenous access, and venipuncture should never be performed on the affected extremity because of the potential for infection and clotting of the fistula; therefore, eliminate options 1 and 2. The only option that relates to the subject of this question is option 4. Priority Nursing Tip: For the client receiving hemodialysis, the AV fistula is the client's lifeline, and the client's hemodynamic status should be closely monitored. Clients will need teaching on which medications to avoid before dialysis. Reference: Ignatavicius, Workman, Rebar (2018), p. 1415..